A client has a herniated lumbar disk at L5. The nurse knows that which of the following symptoms needs to be immediately reported to the RN or physician?

A. A blood pressure cuff is not directly needed to assess neurological status. While blood pressure is important to monitor in neurological assessments, it is not the primary tool used for assessing neurological function.

B. A pen light is essential for assessing pupil reaction, which is a key part of a neurological exam. The nurse can use the pen light to check for pupil dilation, constriction, and reaction to light, which are important indicators of brain function.

C. A thermometer is useful for measuring body temperature but is not a primary tool for assessing neurological status. Although fever can be a sign of infection affecting the brain, it is not part of the basic neurological exam.

D. A stethoscope is useful for listening to heart and lung sounds, but it is not typically used for assessing neurological function. The pen light is the more appropriate tool for this purpose.

A. A positive Romberg sign (difficulty maintaining balance with eyes closed) can indicate a neurological issue, but it is not directly associated with a migraine.

B. A subnormal temperature (low body temperature) is not typically associated with migraines and may indicate another issue, but it is not as concerning as other findings.

C. An ill college roommate might suggest a viral illness, but it is not a direct concern for the student’s migraine. Migraines are not contagious, and other signs of illness would be more concerning.

D. Positive Brudzinski sign, which involves involuntary flexion of the hips and knees when the neck is flexed, is indicative of meningeal irritation, a sign of meningitis. This is a medical emergency and much more concerning than the symptoms of a migraine. The student should be further assessed for signs of meningitis, which requires urgent treatment.